Medicaid Services Chart - Department of Health | State of ...

[Pages:44]. LOUISIANA DEPARTMENT OF HEALTH

MEDICAID SERVICES CHART

October 2022

1 * Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts for questions regarding coverage of services not listed on this chart. NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Healthy Louisiana Plan members should contact their Plan's member services department with questions about how to access care

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MEDICAID SERVICES

SERVICE

HOW TO ACCESS SERVICES

ELIGIBILITY

COVERED SERVICES

COMMENTS

CONTACT PERSON

Adult Denture Services

Dentist

Medicaid recipients 21 years of age and older.

(Adults, 21 and over, certified as Qualified Medicare Beneficiary (QMB), Specified Low Income Medicare Beneficiary (SLMB) only, PACE, Take Charge Plus or other programs with limited benefits are not eligible for dental services.)

Examination, x-rays (are only covered if in conjunction with the construction of a Medicaidauthorized denture) dentures, denture relines, and denture repairs.

Only one complete or partial denture per arch is allowed in an eight-year period. The partial denture must oppose a full denture. Two partials are not covered in the same oral cavity (mouth). Additional guidelines apply.

DentaQuest and MCNA Dental administer the dental benefits for eligible Medicaid recipients. Contact your plan to locate a network provider and for questions about covered dental services.

DentaQuest 1-800-685-0143

Visit online at DentaQuest.co m

MCNA Dental 1-855-702-6262

Visit online at

Kevin Guillory 225/342-7476

Tiffany Hayes 225/342-7877

2 * Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts for questions regarding coverage of services not listed on this chart.

NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Healthy Louisiana Plan members should contact their Plan's member services department with questions about how to access care

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MEDICAID SERVICES

SERVICE

HOW TO ACCESS SERVICES

Adult Waiver Dental Dentist Services

ELIGIBILITY

COVERED SERVICES

COMMENTS

CONTACT PERSON

Medicaid recipients 21 years of age and older enrolled in New Opportunities Waiver, Residential Options Waiver or Supports Services Waiver.

The Adult Waiver Dental Program provides coverage of certain diagnostic; preventive; restorative; endodontic; periodontic; removable prosthodontic; maxillofacial prosthetic; oral and maxillofacial surgery; orthodontic; and adjunctive general services. Specific policy guidelines apply.

DentaQuest and MCNA Dental administer the dental benefits for eligible Medicaid recipients. Contact your plan to locate a network provider and for questions about covered dental services.

DentaQuest 1-800-685-0143

Visit online at DentaQuest.co m

MCNA Dental 1-855-702-6262

Visit online at

Kevin Guillory 225/342-7476

Tiffany Hayes 225/342-7877

3 * Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts for questions regarding coverage of services not listed on this chart.

NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Healthy Louisiana Plan members should contact their Plan's member services department with questions about how to access care

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MEDICAID SERVICES

SERVICE

Applied Behavior Analysis (ABA)

HOW TO ACCESS SERVICES

Medicaid enrolled ABA provider

ELIGIBILITY

Age from birth up to 21 years of age; and

(1) exhibit the presence of excesses and/or deficits of behaviors that significantly interfere with home or community activities (examples include, but are not limited to aggression, self-injury, elopement, etc.);

COVERED SERVICES

ABA-based therapy services shall be rendered in accordance with the individual's treatment plan.

COMMENTS

All medically necessary services must be prescribed and Prior Authorized. The provider of services will submit requests for Prior Authorization.

(2) be diagnosed by a qualified health care professional with a condition for which ABA-based therapy services are recognized as therapeutically appropriate, including autism spectrum disorder;

(3) have a comprehensive diagnostic evaluation by a qualified health care professional; and

CONTACT PERSON

Aetna aetnabetterhea louisiana

AmeriHealth Caritas amerihealthca

Healthy Blue myhealthyblu

Louisiana Healthcare Connections louisianahealt

United Healthcare Community Plan uhccommunit

(4) have a prescription for ABAbased therapy services ordered by a qualified health care professional.

Rene Huff 225/342-3935

4 * Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts for questions regarding coverage of services not listed on this chart.

NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Healthy Louisiana Plan members should contact their Plan's member services department with questions about how to access care

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MEDICAID SERVICES

SERVICE

HOW TO ACCESS SERVICES

Audiological Services ?See EarlySteps; EPSDT Screening Services; Hospital-Outpatient services; Physician/ Professional Services; Rehabilitation Clinic Services; Therapy Services

ELIGIBILITY

COVERED SERVICES

COMMENTS

CONTACT PERSON

5 * Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts for questions regarding coverage of services not listed on this chart.

NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Healthy Louisiana Plan members should contact their Plan's member services department with questions about how to access care

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Behavioral Health Services ? Adults

Any Medicaid eligible adult may receive the following behavioral health service if medical necessity is established by a licensed mental health professional (LMHP).

Medicaid eligible adult

Adults eligible to receive mental health rehabilitation services under Medicaid State Plan include those who meet the following criteria and is 21 years and older:

Must have a mental health diagnosis and

Must be assessed by an LMHP

1. Community Psychiatric Support & Treatment

2. Psychosocial Rehabilitation 3. Crisis Intervention 4. Assertive Community Treatment 5. Outpatient Therapy with Licensed

Practitioners (medication management, individual, family, and group counseling) 6. Addiction Services (outpatient, residential, and inpatient) 7. Psychiatric Inpatient Hospital 1821 years and over 65 years of age

Adult Behavioral Health services are administered by the Healthy Louisiana Plans. CPST, PSR and ACT must be Prior Authorized.

Members receiving CPST and/or PSR:

Must have at least a level of care of three on the LOCUS.

Must have a rating of three or greater on the functional status domain on the level of care utilization system (LOCUS).

LOCUS score are not required to receive LMHP services.

For more information, please refer to the BHS Provider Manual.

Aetna aetnabetterhea louisiana 1-855-242-0802

AmeriHealth Caritas amerihealthca 1-888-756-0004

Healthy Blue myhealthyblu 1-844-521-6941

Louisiana Healthcare Connections louisianahealt 1-866-595-8133

United Healthcare Community Plan uhccommunit 1-844-253-0667

6 * Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts for questions regarding coverage of services not listed on this chart.

NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Healthy Louisiana Plan members should contact their Plan's member services department with questions about how to access care

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MEDICAID SERVICES

SERVICE

HOW TO ACCESS SERVICES

ELIGIBILITY

COVERED SERVICES

COMMENTS

CONTACT PERSON

Chemotherapy Services-See Hospital-Outpatient Services; Physician/ Professional Services

Hospital

Physician's office or clinic

All Medicaid Recipients.

Chemotherapy administration and treatment drugs, as prescribed by physician.

Becky Mouton 225/342-4722

Chiropractic Services

EPSDT Medical Screening Provider/PCP

Medicaid recipients 0 through 20 years of age.

Spinal manipulations.

Medically necessary manual manipulations of the spine when the service is provided as a result of a referral from an EPSDT medical screening provider or Primary Care Provider (PCP).

Becky Mouton 225/342-4722

7 * Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts for questions regarding coverage of services not listed on this chart.

NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Healthy Louisiana Plan members should contact their Plan's member services department with questions about how to access care

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Coordinated System of Care (CSoC) Program

To make a referral, contact the child/youth's Healthy Louisiana Plan. Note that the parent/caregiver must participate in the referral. The Healthy Louisiana Plan information is as follows:

Aetna Better Health: 1-855242-0802

AmeriHealth Caritas: 1-888756-0004

Healthy Blue: 1844-521-6941

Children, youth and families eligible for CSoC include Medicaid members between the ages of 5 and 20 years of age, who have a severe emotional disturbance (SED) or a serious mental illness (SMI) and who are in or at risk of out of home placement. A recipient meet the level of care or level of need through a Child and Adolescent Needs and Strengths (CANS) comprehensive assessment.

CSoC services are administered by Magellan Health Services of Louisiana.

Magellan Health Services of Louisiana 1-800-424-4489

1. Parent Support & Training 2. Youth Support & Training 3. Independent Living/Skills

Building 4. Short Term Respite Care 5. Case Conference

Louisiana Healthcare Connections: 1866-595-8133

For more information, please refer to the BHS Provider Manual.

United Health Care: 1-866-6751607

**The Healthy Louisiana Plan will connect you with Magellan to

8 * Exclusion from this list does not necessarily mean that a service is not covered. Please call one of the appropriate contacts for questions regarding coverage of services not listed on this chart.

NOTE: The points of contact listed in this document is applicable to Medicaid recipients in the fee-for-service Medicaid program. Healthy Louisiana Plan members should contact their Plan's member services department with questions about how to access care

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